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BACKGROUND: Salvage intravesical therapies have limited efficacy in treating carcinoma in situ of the bladder (CIS) following failure of two 6-week courses of BCG. In fact, the repeated use of intravesical agents may delay appropriate timing of radical cystectomy. Here we examine a cohort of patients with CIS who underwent radical cystectomy to determine whether timing of surgery correlates with pathologic upstaging.
METHODS: Of patients undergoing radical cystectomy at our institution, 62 consecutive patients with a primary diagnosis of CIS were identified. Based on the time required for evaluation and treatment of patients during two induction courses of intravesical BCG, early cystectomy was considered ≤12 months from initial diagnosis. All patients underwent a standard template nodal dissection. Subgroup analysis was conducted to determine the effects of surgical timing on pathologic stage utilizing chi-square and Student’s t-test.
RESULTS: Of 62 patients who were diagnosed with CIS and underwent radical cystectomy, 14 (23%) underwent surgery ≤12 months from diagnosis, and 48 (77%) in >12 months. Patients in the late cystectomy group on average underwent a significantly greater number of intravesical chemotherapy cycles as opposed to the early group (2.6 vs 1.4, p<0.03). Furthermore, patients in the late cystectomy group were significantly more likely to have occult nodal metastases on pathologic analysis (0% vs 22.9%, p<0.05).
CONCLUSIONS: In patients with CIS, delaying radical cystectomy beyond 12 months can adversely affect prognosis with an increased risk of nodal metastasis. These findings do not support prolonged bladder sparing approaches to treatment following failure of BCG.